45 lines
1.2 KiB
Plaintext
45 lines
1.2 KiB
Plaintext
<form method="POST">
|
|
<h3>Vertrag</h3>
|
|
|
|
<label>Vertragsnummer</label>
|
|
<input
|
|
type="text"
|
|
class="form-control mb-2 bg-light"
|
|
placeholder="Wird automatisch vergeben"
|
|
disabled>
|
|
|
|
<label>Vertragsvariante</label>
|
|
<input
|
|
type="number"
|
|
name="vertragsvariante"
|
|
class="form-control mb-2"
|
|
placeholder="z. B. 1, 2 oder 3"
|
|
required>
|
|
<h3>Persönliche Daten</h3>
|
|
<input name="vorname" placeholder="Vorname" required>
|
|
<input name="nachname" placeholder="Nachname" required>
|
|
|
|
<label>Geburtsdatum</label>
|
|
<input type="date" name="geburtsdatum" required>
|
|
|
|
<h3>Adresse</h3>
|
|
<input name="strasse" placeholder="Straße">
|
|
<input name="hausnummer" placeholder="Hausnummer">
|
|
<input name="plz" placeholder="PLZ">
|
|
<input name="ort" placeholder="Ort">
|
|
<input name="land" placeholder="Land">
|
|
|
|
<h3>Kontakt</h3>
|
|
<input name="mobil" placeholder="Mobilnummer">
|
|
<input name="telefon" placeholder="Telefonnummer">
|
|
<input name="email" type="email" placeholder="E-Mail">
|
|
|
|
<h3>SEPA Lastschrift</h3>
|
|
<input name="kontoinhaber" placeholder="Kontoinhaber">
|
|
<input name="iban" placeholder="IBAN">
|
|
<input name="bic" placeholder="BIC">
|
|
<input name="mandatsreferenz" placeholder="Mandatsreferenz">
|
|
|
|
<button>Speichern</button>
|
|
</form>
|